This subproject is one of many research subprojects utilizing the resources provided by a Center grant funded by NIH/NCRR. The subproject and investigator (PI) may have received primary funding from another NIH source, and thus could be represented in other CRISP entries. The institution listed is for the Center, which is not necessarily the institution for the investigator. Define the efficacious therapies for cerebral small artery disease and its two most common clinical manifestations: small subcortical strokes and cognitive decline. Optimal antiplatelet therapy and antihypertensive management of patients to reduce stroke recurrence and cognitive decline has not been defined and is likely to yield important health benefits. Although MRI-defined symptomatic small subcortical strokes in the absence of surgically amenable cervical carotid stenosis and major-risk cardioembolic sources is the qualifying event for participation in the study and recurrent stroke is the primary outcome, the goals of the study are broader in scope and include assessment and prevention of vascular dementia. This study will define optimal treatment to prevent recurrent stroke and cognitive decline for patients without an indication for endarterectomy or anticoagulation.